Ann Borders, MD, MSc, MPHExecutive Director, OB Lead, ILPQC
NJPQC Perinatal Safety ConferenceApril 29th, 2019
Illinois Perinatal Quality Collaborative
Severe Maternal Hypertension Initiative
Illinois Perinatal Quality Collaborative (ILPQC)• Multi-disciplinary, multi-stakeholder
Perinatal Quality Collaborative with 117 Illinois hospitals participating in 1 or more initiative
• Support participating hospitals’ implementation of evidenced-based practices using quality improvement science, collaborative learning and rapid response data
2
>95% of IL births
ILPQC Milestones• IL Perinatal Advisory Committee Prematurity Task Force Report• Start Up Funding: CHIPRA / HFS• Stakeholder Meetings Begin
2012
• Consultation with Perinatal Quality Leaders (OH, CA, NC, FL)• Website Launch• ILPQC Kick-Off, 1st Annual Conference
2013
• ILPQC Data System Launched• CDC Award with IDPH• Launch EED and Neonatal Nutrition Initiatives
2014
• Launch Golden Hour Initiative• Launch Birth Certificate Initiative• Started yearly spring Face to Face Meetings for OB and Neo Teams
2015
• Launch Maternal Hypertension Initiative• IDPH Funding• Golden Hour Initiative Ongoing
2016
• Maternal Hypertension and Golden Hour Initiatives Ongoing• CDC Funding for MNO Initiative• Pritzker Grant Award for IP LARC Initiative
2017
• Launch Mothers and Newborns affected by Opioids (MNO) Initiative• Launch Immediate Postpartum LARC Initiative• Launch Sustainability for Maternal Hypertension and Golden Hour Initiatives
2018
ILPQC Infrastructure
ILPQC Central TeamAnn Borders ILPQC Executive Director, OB Lead
Leslie Caldarelli & Justin JosephsenNeonatal Leads
Patricia Lee King State Project Director
Daniel Weiss & Danielle YoungProject Coordinators
Autumn Perrault Nurse Quality Manager
[email protected] OR www.ilpqc.org
6
Leadership, Advisors, Stakeholders, Patients/Families
QI Implementation Model:Building Hospital Capacity to Drive Systems & Culture Change
ILPQC Provides Responsive QI Services to Hospital Teams
Webinars/ Calls•Monthly & quarterly
collaborative learning and QI Topic Calls
•QI Support Calls with Perinatal Network Administrators• Key players meeting• RedCap data training
Face to Face• Spring Face-to-Face
Meeting Breakouts• Annual Conference
Breakouts• Key Player Site
Visits• Grand Rounds
speakers group
ILPQC Resources• Paper/online QI
toolkits• Patient-education
materials• Monthly e-
newsletters• Previous months
webinar recording
ILPQC Data• Rapid Response
data system• Real-time reports
for teams to compare data across time & hospitals
Quality Improvement Support Services
Why we do this work
6% of preterm births, and 19% of medically-indicated induced
preterm births
1/3 of severe obstetric
complications
IUGR,oligohydramnios, placental abruption, NICU admission,
stillbirth, neonatal death
9% of maternal deaths in the United States
Severe Maternal
Hypertension Preeclampsia:4-10% US pregnancies
9
Why we do this work
Importance of Timely Treatment of Severe Maternal Hypertension• Primary cause of maternal death is hemorrhagic
stroke caused by untreated severe hypertension • National guidelines recommend timely treatment of
severe hypertension < 60 min to reduce maternal stroke and severe maternal morbidity, endorsed by ACOG
• Alliance for Innovation on Maternal Health (AIM) Severe Hypertension in Pregnancy Maternal Safety Bundle
10
Aim: Reduce the rate of severe morbidities in women with severe preeclampsia, eclampsia, or preeclampsia superimposed on pre-existing hypertension by 20% by December 2017Approach: 4 key goals1. Reduce time to treatment2. Improve postpartum patient education3. Improve postpartum patient follow up4. Improve provider & RN debrief
ILPQC Maternal Hypertension Initiative
• 110 hospital teams - May 2016 kick off to December 2017• 106 Hospitals submitted data for over 17,000 women who experienced
severe maternal HTN across the initiative• Sustainability started January 2018 • 86 teams have submitted sustainability data
Incorporating the AIM Severe HTN in Pregnancy Bundle • Incorporated AIM Bundle resources in ILPQC
Severe Maternal HTN toolkit binder (paper and online) and incorporated into collaborative learning calls
• Adapted IHI Implementation Checklist and AIM Quarterly Measures as structure measures to monitor implementation
• Incorporated AIM eModules across hospitals for provider/nurse education towards culture change
Project Aims
13
By December 2017, for all women with confirmed severe maternal HTN across participating hospitals:
Goal
Increase the proportion of women treated for severe HTN in < 60 minutes
≥ 80%
Increase the proportion of women receiving preeclampsia education at discharge
≥ 80%
Increase the proportion of women with follow-up appointments scheduled within 10 day of discharge
≥ 80%
Increase the proportion of cases with provider / nurse debriefs
≥ 50%
Reduce the rate of severe maternal morbidity (SMM) ↓20%
How do we improve care?
• Early recognition of hypertension and correct diagnosis during and after pregnancy
• Reduce time to treatment of severe range blood pressure, 160/110(105)
• Provide patient education and appropriately timed follow up
• Implementation of evidence based protocols for treatment and management of severe HTN / preeclampsia / eclampsia
Controlling blood pressure is the optimal intervention
to prevent deaths due to stroke in women with preeclampsia.
Key Clinical Pearl:160/110 vs. 160/105
The critical initial step in decreasing maternal morbidity and mortality is to administer anti-hypertensive medications as soon as possible (< 60 minutes) of documentation of persistent (retested within 15 minutes) BP ≥160 systolic, and/or >105-110 diastolic
Clark SL, Hankins GD. Preventing maternal death: 10 clinical diamonds. Obstet Gynecol 2012;119:360–4.
BP ≥ 160/110(105)
NeedTo
Treat*
*BP persistent 15 minutes, activate treatment algorithm with IV therapy ASAP, < 30-60 minutes
Quality Improvement Focus• Provider / staff education and standardized BP
measurement• Rapid access to medications• IV treatment of BP’s ≥ 160mmHg systolic or ≥
110(105) mmHg diastolic within 30-60 min• Standardize treatment algorithms / order sets • Provider / nurse debrief time to treatment• Early postpartum follow-up• Standardized postpartum patient education
Quality Improvement StrategyILPQC facilitated:• Development of hospital-based QI teams by April 2016• Collaborative learning through 4 in-person meetings,
21 monthly webinars, and 15 QI topic calls with teams • Rapid-response data system for teams to compare
data across time and to other hospitals• QI support through a toolkit, network meetings, and
QI coaching calls to individual hospital teams • Regular communications including twice-monthly e-
newsletters to teams and website with resources
18
Quality Improvement StrategyHospital teams facilitated:• Representatives from each team at twice yearly
in-person ILPQC meetings • Monthly participation in ILPQC webinars• Collection and submission of monthly QI data and
quarterly structure measures to ILPQC Data System
• Monthly QI team meetings to review data and develop and implement QI strategies with Plan Do Study Act (PDSA) cycles
19
• Monthly hospital team webinars review data, QI focus, Team Talks
• Hospital QIsupport calls
• Website for resources
• Monthly e-newsletters per initiative
• Face-to-Face meetings / Annual Conference – Teams enjoy meeting in-person, sharing, learning from each other
and networking– Breakout sessions for time to discuss issues – Story boards and poster sessions allow teams to share progress
Communication is Key
Severe Hypertension TreatmentAlgorithm
IV Anti-Hypertension Meds
First Line Medications
IV Labetalol 20 mg (over 2 min)
IV Hydralazine 5 or 10mg (over 1-2 min)
Per physician’s orderRepeat BP in 10 min
If elevated, administerIV Labetalol 40 mg
Repeat BP in 10-15 min If elevated, administerIV Labetalol 80 mg
Repeat BP in 20 minIf elevated,
IV Hydralazinepre algorithm
anesthesia consult
Repeat BP in 20 minIf elevated, administer
IV Hydralazine 10 mg
Repeat BP in 20 minIf elevated, IV
Labetalol 20 mgpre algorithm
anesthesia consult
Repeat BP in 20 minIf elevated, administer
IV Hydralazine 10 mg
Blood Pressure TriggersSBP ≥ 160 and/or DBP ≥ 110
Repeat in 15 minutes.
Notify Provider and Proceed
IV AccessFHR monitoring
Labs per PIH Order Set Pulse Oximeter
SBP > 155 and/or DBP > 105Provider Notified
Seizure Prophylaxis
Magnesium Sulfate
Bolus Dose: 4gm over 20 minutesMaintenance Dose: 2gm per hour
PO Nifedipine If no IV access Initial Dose: 10 mg
May repeat dose at 20 minute intervals for a maximum of
5 doses.
Data Collection• Process and outcome measures collected by ongoing monthly
chart review by hospital teams• Inclusion criteria
– All first cases of severe maternal HTN during pregnancy through 6 weeks postpartum in participating hospitals
– Severe Maternal HTN defined as BP ≥ 160/110 persistent for ≥ 15 minutes
• Timeline– Baseline: October – December 2015– Initiative Launch May 2016– Monthly data collection through December 2017– Monthly compliance data collection ongoing
22
Key Measures• Outcome: Severe Maternal Morbidity• Process: Time to treatment, Patient discharge
education, Patient follow up visit< 10 days, Debrief• Balancing: Hypotension, Fetal heart rate• Structure:
– Facility-wide protocols for timely identification and treatment of severe maternal hypertension
– Provider /nurse education on HTN protocols– Rapid access to IV medications– System plan for escalation of care– Facility-wide protocols for patient education
23
ILPQC Data System
24
Hospital Teams immediately access rapid response web based reports to compare data across time and to other IL hospitals
Hospital Teams enter monthly outcome, balancing and process and quarterly structure measures into REDCap
Hospital Teams collect data through chart audit and real time data logs
ILPQC Data System
• ILPQC HTN Data Form• REDCap Data Portal• Real-Time Data Reports
25
Reducing Time To Treatment
86% 84%
70%
58%
35% 33%29% 27%
8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Elements of Maternal Hypertensive Bundle Most Effective in Reducing Time to Treatment
ILPQC Team Survey, 2017
Strategies to Reduce Time to Treatment• Partner with pharmacy for quicker access to IV HTN meds in all
units using: standing orders, availability in PYXIS & override of antihypertensives
• Changing policies on telemetry with IV meds, labetalol• Facilitate consistent and timely interdepartmental
communication using: nurse champions to carry to all units; debriefs, huddles, daily rounds, individual feedback to discuss cases; share REDCap data with staff and providers
• Adapt and implement protocols, checklists, and standard order sets across units
Structure Measure:Standard Policies / Protocols Across Units
0%
20%
40%
60%
80%
100%
Q2 2016 (Apr-Jun) (N=21)
Q3 2016 (Jul-Sep) (N=32)
Q4 2016 (Oct-Dec) (N=41)
Q1 2017 (Jan-Mar) (N=51)
Q2 2017 (Apr-Jun) (N=47)
Q3 2017 (Jul-Sep) (N=30)
Percent of hospitals with standard protocols for early warning signs, updated diagnostic criteria, monitoring and treatment of severe
preeclampsia/eclampsia (include order sets and algorithms)
L&D Ante/postpartum Triage/ED
Strategies to Implement Protocols / Order Sets
• Develop interdisciplinary committee to review algorithms and order sets for implementation using Plan/Do / Study / Act = small test of change = test 1 provider, 1 patient, 1 day or test 1 unit for 1 week
• Integrate into EMR• Develop easily accessible printed algorithms & order sets (e.g.
bedside clipboard, pocket card order sets)• Use key words in nurse provider communications: “your
patient has severe range hypertension”, report BPs, “I would like to activate severe HTN protocol”
• Post severe HTN time to treatment sign across units
Effective Steps to ImplementStandard Protocols
We reiterate what the goal is at physician OB department meetings and work closely with OB chair to promote an overall culture of safety where the chain of command is used and event reporting is done to determine trends.
We use common order set for all units. ED knows that they have the full support of the OB unit and can call at anytime for us to facilitate the treatment of possible patient
We have updated policies and created a protocol for management of severe HTN that is posted in all rooms with other visual aides.
ILPQC Team Survey, 2017
31
Structure Measure:Provider & Nurse Education
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Q2 2016(N=60)
Q3 2016(N=61)
Q4 2016(N=56)
Q1 2017(N=61)
Q2 2017(N=58)
Q3 2017(N=41)
Perc
ent C
ompl
eted
Edu
catio
n
Quarter (Respondents)
Culumative percent of OB providers and nurses completed (within the last 2 years) implementation education on the Severe
HTN/Preeclampsia bundle elments and unit-standard protocol
Series1 Series2Providers Nurses
Education Tools for Physician/Nurse Buy In
AIM eModules Severe Maternal HTN Grand Rounds
Available on AIM website. Quiz at end withcertificate - can ask providers/staff to submitcertificate. View eModules here.
Available to download from ILPQC website (or click here).Speakers group available to provide Grand Rounds acrossthe state. Email [email protected] for more information.
Effective Steps to ImplementEducation Program
We identified RN and MD champions for the whole hospital along with unit champions and have the support of nursing administration
We used consistent reminders after education in huddles and unit meetings and audited charts.
We incorporated HTN education as part of nursing skills day yearly. All new staff and physicians will be educated using the comprehensive slide set.
We have included the education into our computer modules and have made it an annual requirement. We have also included maternal hypertension simulations
ILPQC Team Survey, 2017
QUALITY IMPROVEMENT RECOGNITION AWARD WINNERSILPQC SEVERE MATERNAL HYPERTENSION INITIATIVE
“I truly believe this was a great initiative that brought awareness and management of this disease starting from the clinic visits until 6 weeks postpartum. Time of treatment is crucial and this initiative has brought attention to all the staff managing these patients.”
Maternal Hypertension Data: Time to Treatment
Maternal Hypertension Data:Patient Education
All Hospitals, 2016-2018
Maternal Hypertension Data:Patient Follow-up
All Hospitals, 2016-2018
Severe Maternal Hypertension Time To Treatment Debriefed
38
Maternal Hypertension Outcome Data: Severe Maternal Morbidity
15%
17%
23%
15%
13%
15%16%
14%
12%
18%
9%
16%
10% 11%
17%
11%
13%
8%
12%
10%
9%9% 9%
0%
5%
10%
15%
20%
25%
Perc
ent o
f Wom
en
ILQPC: Women with New Onset HTN with Severe Maternal MorbidityAll Hospitals, 2016-2017
All Maternal Outcomes
Severe Maternal Morbidity Diagnoses:
• Intracranial Hemorrhage or Ischemic event (stroke)
• Eclampsia• Pulmonary Edema• HELLP Syndrome• Oliguria• DIC• Renal Failure• Liver Failure• Ventilation• Placental Abruption• OB Hemorrhage• ICU Admission
15%
40% Change! 9%
13,263 patients included
Severe Maternal Morbidity RateDeliveries with Hypertension, Hospital Discharge Data, All Illinois Hospitals
40
10.3%
8.4%
6.9% 7.1% 6.9%
5.4%
6.5%
4.9% 5.1%
0%
2%
4%
6%
8%
10%
12%
'15Q4 '16Q1 '16Q2 '16Q3 '16Q4 '17Q1 '17Q2 '17Q3 '17Q4
Perc
ent e
xper
ienc
ing
SMM
Year / Quarter
Between 2015-Q4 and 2017-Q4, the SMM rate among women experiencing hypertension at delivery was cut in half.
50%
Hypertension Sustainability
41
Compliance Monitoring
New Hire Education
Ongoing Staff/Provider Education
Sustainability Plan
Building HTN Sustainability Post-Initiative: All teams submit a Severe HTN Sustainability Plan 1. Compliance tracking for all cases severe HTN in
ILPQC Data System, plan for monitoring & response• Time to treatment severe HTN under an hour• Magnesium provided• Early follow up for BP check within 7-10 days• Patient education at discharge
2. Ongoing education for providers and nurses (drills, simulations, e-modules)
3. Education plan for new hires
42
Compliance Monitoring for HTN
Hospital TeamsMonthly Data Reporting and
Review at Meetings
Perinatal Network Administrators
Outreach
ILPQCQI Support and Quarterly Team Check in Calls
43
Sustained Improvements
Mentorship Model
HTN Goals in 2019• Every hospital maintain Time to Treatment above
goal – benchmark and review data• Maintain sustainability plan
– Continue compliance monitoring– New hire education– Continued education
• Review missed opportunities with providers/staff• ILPQC will maintain RedCap Data Reports• 2 HTN webinars in 2019 with Team Talks to discuss
ongoing sustainability work
44
THANKS TO OURFUNDERS
ADDITIONAL INFORMATION
47
Role of Nurses & Staff• Know best practices for accurate blood pressure management• Identify severe range BP >160/105-110, notify provider and repeat with in
15 minutes.• If repeat BP remains elevated, notify provider of BP and need to activate
severe range BP treatment protocol for IV therapy• Have easy access to protocol / order set to ensure correct intervals for
repeating BP and redose medications.• Systems in place for easy rapid access to medications• Follow protocols to start Magnesium for seizure prevention• Ensure all patients with hypertension have appropriate follow up with in 7-
10 days, if home on meds f/u 72 hours for BP.• Ensure all patients are given standard education on postpartum
preeclampsia• Remember to Debrief “How did we do on Time to Treatment?”
48
Role of OB providers• If notified of severe range BP
– Follow ACOG treatment guidelines for IV therapy and BP reassessment and escalation of therapy
– Goal is therapy ASAP within 30-60 minutes of confirmed elevated BP
– Magnesium for seizure prevention for new onset severe HTN
– Determine need for immediate evaluation– Participate in Debrief with nurse (How did we do on Time
to Treatment? Any barriers? What went well?)
49
Role of OB providers• Discharge Management
– All postpartum patients with chronic HTN/ gest HTN / preeclampsia need early postpartum follow up within 7-10 days to evaluate BP
– For patients on BP medication consider follow up within 72 hours to confirm BP controlled
– Standardize preeclampsia education for prenatal and postpartum patients
50
ToolkitToolkit includes example:• Protocols• Checklists• Provider education modules• Patient education materials• Order sets• Drills and simulations
51
GET READYIMPLEMENT STANDARD PROCESSES for optimal care of severe maternal hypertension in pregnancy
RECOGNIZEIDENTIFY pregnant and postpartum women and ASSESS for severe maternal hypertension in pregnancy
Develop standard order sets, protocols, and checklists for recognition and response to severe maternal hypertension and integrate into EHR
Ensure rapid access to IV and PO anti-hypertensive medications with guide for administration and dosage (e.g. standing orders, medication kits, rapid response team)
Educate OB, ED, and anesthesiology physicians, midwives, and nurses on recognition and response to severe maternal hypertension and apply in regular simulation drills
Implement a system to identify pregnant and postpartum women in all hospital departments
Execute protocol for measurement, assessment, and monitoring of blood pressure and urine protein for all pregnant and postpartum women
Implement protocol for patient-centered education of women and their families on signs and symptoms of severe hypertension
RESPONDTREAT in 30 to 60 minutes every pregnant or postpartum woman with new onset severe hypertension
CHANGE SYSTEMSFOSTER A CULTURE OF SAFETY and improvement for care of women with new onset severe hypertension
GOAL: To reduce preeclampsia maternal morbidity in Illinois hospitalsKey Driver Diagram: Maternal Hypertension Initiative
Key Drivers Interventions
Establish a system to perform regular debriefs after all new onset severe maternal hypertension cases
Establish a process in your hospital to perform multidisciplinary systems-level reviews on all severe maternal hypertension cases admitted to ICU
Incorporate severe maternal hypertension recognition and response protocols into ongoing education (e.g. orientations, annual competency assessments)
AIM: By December 2017, to reduce the rate of severe morbidities in women with preeclampsia, eclampsia, or preeclampsia superimposed on pre-existing hypertension by 20%
Execute protocols for appropriate medical management in 30 to 60 minutes Implement a system to provide patient-centered discharge education materials on
severe maternal hypertension Implement protocols to ensure patient follow-up within 10 days for all women with
severe hypertension and 72 hours for all women on medications
